Alabama Board of Medical Examiners Volume 22, Number 2 www.albme.org Newsletter and Report Inside: 2007 Legislative Update Be aware of new laws that will impact physicians. – page 2 Federation of State Medical Boards Read highlights from the FSMB annual meeting. – page 3 Notices New rules will affect Medicaid prescriptions, collaborative agreements and more. – page 6 Board welcomes new member Birmingham anesthesiologist Paul Nagrodzki, MD, joined the Board in April. – page 7 Q&A Find answers to common questions on electronic prescribing and CRNPs. – page 8 Closing a practice Learn how to prepare for the unexpected. – page 9 Public Actions Report from April – June 2007. – page 11 April – June 2007 A physician has several ways to provide a patient with medications outside of a healthcare facility – administering medica- tion in the physician’s office or practice site, providing a supply of medication for a patient to use away from the practice site, and, the most common, writ- ing a prescription to be filled by a pharmacist. Administration of a medica- tion, such as an injection, in a physician’s practice site requires adequate documenta- tion in the patient’s record of the rationale for the medicine, the dosage and the method of administration. If the adminis- tered drug is a controlled substance, the physician must maintain appropriate con- trols as enumerated in Board Rule 540-X- 4-.03. [See the Newsletter Links section at www.albme.org.] A physician who gives medicines from the office to be taken or used by a patient off site requires docu- mentation similar to the previous situation. If controlled sub- stances are purchased for dispensing for off-site use, the physi- cian must register with the Board as a dis- pensing physician and follow the Alabama Department of Public Health reporting requirements for dispensing physicians. [See the Newsletter Links section at www.albme.org.] When a physician gives only prepackaged samples of controlled substances to a patient, registration and reporting are not required. In either case, the controlled substances must be main- tained with appropriate controls and according to Board Rule 540-X-4-.03. Presently, using a written or electronic prescription is the most common way to provide a patient with medication. A pre- scription is a written, verbal or electronic request to the pharmacist to supply the patient with a described medicine, in a described strength, and in a described amount, with instructions on how to take it and with the physician’s signature indicating responsibility. All physicians learn the basics of prescribing medicine in medical school. When a physician goes astray, it is often through haste, compassion for a patient or family member, lack of understanding newly introduced drugs or lack of appreciation of new techniques for prescribing. The few, fortunately a small number, physicians who use prescribing as a way to increase their income, cause the need for many rules that all physicians must follow. This article will review some problems frequently seen by the Board related to physicians’ prescriptions. Never, never leave signed blank pre- scriptions anywhere: not in the office, car, or medical care facility. A physi- cian’s signature is a privilege to write for prescriptive medicines. Physicians who leave signed blank prescriptions so that medications can be given to their patients in their absence generate temptations to Avoid common prescription problems Tamper-proof prescription pads will be required for all written Medicaid prescriptions as of Oct. 1, 2007. See the notice on page 6 for more details. (continued on page 3) Never leave signed blank prescriptions anywhere.
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Alabama Board of Medical Examiners
Volume 22, Number 2www.albme.org
Newsletter and Report
Inside:2007 Legislative Update
Be aware of new laws that
will impact physicians.
– page 2
Federation of StateMedical Boards
Read highlights from the
FSMB annual meeting.
– page 3
NoticesNew rules will affect
Medicaid prescriptions,
collaborative agreements
and more.
– page 6
Board welcomes newmember
Birmingham anesthesiologist
Paul Nagrodzki, MD, joined
the Board in April.
– page 7
Q&AFind answers to common
questions on electronic
prescribing and CRNPs.
– page 8
Closing a practiceLearn how to prepare for
the unexpected.
– page 9
Public ActionsReport from April – June
2007.
– page 11
April – June 2007
A physician has several ways to provide
a patient with medications outside of a
healthcare facility – administering medica-
tion in the physician’s office or practice
site, providing a supply of
medication for a patient to use
away from the practice site,
and, the most common, writ-
ing a prescription to be filled
by a pharmacist.
Administration of a medica-
tion, such as an injection, in a
physician’s practice site
requires adequate documenta-
tion in the patient’s record of
the rationale for the medicine,
the dosage and the method of
administration. If the adminis-
tered drug is a controlled substance, the
physician must maintain appropriate con-
trols as enumerated in Board Rule 540-X-
4-.03. [See the Newsletter Links section atwww.albme.org.]
A physician who gives medicines from
the office to be taken or used by a patient
off site requires docu-
mentation similar to
the previous situation.
If controlled sub-
stances are purchased
for dispensing for off-site use, the physi-
cian must register with the Board as a dis-
pensing physician and follow the Alabama
Department of Public Health reporting
requirements for dispensing physicians.
[See the Newsletter Links section atwww.albme.org.] When a physician gives
addition, while physicians should not serve as a pri-
mary or regular care provider for immediate family
members, there are situations in which routine care is
acceptable for short-term, minor problems. Except in
emergencies, it is not appropriate for physicians to
write prescriptions for controlled substances for them-
selves or immediate family members.
Do not prescribe controlled substances for an imme-
diate family member except for an urgent situation and
for not more than 48 hours’ dosing. If a physician pre-
scribes a controlled substance in the name of an immediate
family member or for personal use, a red flag rises to the
possibility of diversion or substance abuse by the physician.
Further, due to family dynamics, it is difficult for the
physician to critically assess how much controlled substance
is truly necessary.
New technology, particularly electronic med-
ical records, has created a new method for
transporting the physician’s prescription to the
pharmacist. For legend drugs, the requirements
are the same as for written prescriptions. For controlled
substances, specific laws govern the way that prescriptions
can be submitted. A Class II narcotic may not be filled by
the pharmacist in any way except by a written prescription.
It must be currently dated and signed contemporaneously
by the physician.
Federal Code for Class III, IV and V controlledsubstancesTitle 21, Chapter II, Part 1306 – Prescriptions; Section1306.21 Requirement of prescription(a) A pharmacist may dispense directly a controlled sub-
stance listed in Schedule III, IV or V which is a pre-
scription drug as determined under the Federal Food,
Drug and Cosmetic Act, only pursuant to either:
(1) A written prescription signed by a practitioner; or
(2)A facsimile of a written, signed prescription trans-
mitted by the practitioner or the practitioner’s agent
to the pharmacy; or
(3) Pursuant to an oral prescrip-
tion made by an individual
practitioner and promptly
reduced to writing by the pharmacist containing all
of the information required in Sec. 1306.05, except
for the signature of the practitioner.
The Alabama Board of Pharmacy Administrative Rule,680-X-3-.10 Facsimile Prescription Drug Orders forControlled Substances:
4 (a) A pharmacist may dispense directly a controlled sub-
stance listed in Schedule III, IV or V which is a pre-
scription drug, or any legend drug, only pursuant to:
(1) A written prescription signed by a prescribing indi-
vidual; or
(2) A facsimile of a written signed prescription trans-
mitted directly by the prescribing practitioner, or
the practitioner’s agent, to the pharmacy; or
(3) Pursuant to an oral prescription made by a pre-
scribing individual practitioner, or the practition-
er’s agent, and promptly reduced to writing by the
pharmacist.
According to both state and Federal Codes, an elec-
tronic prescription (e-prescription) for a controlled
substance is not allowed, even with an electronic “sig-
nature.” E-prescribing is elec-
tronically transmitting a prescrip-
tion from a physician’s notebook
computer, hand-held device or
other such instrument directly to
the pharmacy. (See Q&A on page 8.)A physician may not issue an e-prescription for a con-
trolled substance under any circumstance. Pharmacists in
Alabama have complained that they have to remind physi-
cians continuously that they cannot accept an e-prescription
for a controlled substance. The Alabama Board of Pharmacy
has stated that it will enforce its rules against pharmacists
who accept e-formatted controlled substance prescriptions.
Except when covering for another physician or treat-
ing an established patient, a prescription should not be
provided in any form without a personal interview,
examination, and a presumptive diagnosis on which to
base a treatment plan that will include the medication
prescribed. Providing prescriptions for medication via the
Internet is common, but in Alabama it is against Board
Rules. [Rule 540-X-9-.11. See the Newsletter Links sectionat www.albme.org.] Also, see the BME Newsletter,(Volume 21, Issue 3, 2006).
Patients with real pain deserve treatment;
but the management of pain requires an orderly
methodology. Because many patients were being
treated for chronic pain without a reasonable
examination, treatment plan and follow-up procedures, the
Board adopted guidelines for management of chronic pain.
These are consistent with the guidelines accepted by the
Federation of State Medical Boards. The full set of guide-
lines is available from the Board upon request or at the
Although the patient-physicianrelationship is still present,currently healthcare is providedby a system.
Your Medical LicenseAs a physician, your license to practice medicine in the State of Alabama
is one of your most important assets. It allows you to apply what you learned during years of school and post-graduate training to earn a livelihood
to support your family. Exercise care to protect this asset.
Alabama BME Newsletter and Report
Issue 2 • 20076
NoticesMedicaid prescriptions:New CMS rule requires use of tamper-proof prescription pads as of Oct. 1
A new rule by the Centers for Medicare and Medicaid
Services (CMs) will affect every physician in the country
who has Medicaid patients – Medicaid will not reimburse
for prescription medications unless tamper-proof prescrip-
tion pads are utilized. The prescriptions must be water-
marked so that if the prescription is duplicated the bold
word “VOID” appears.
The full text of the new rule is:
REQUIREMENT FOR USE OF TAMPER-RESISTANT PRESCRIPTIONPADS UNDER THE MEDICAID PROGRAM. –
Section 1903(i) of the Social Security Act (42 U.S.C.1396b(i)) is amended... by inserting the followingparagraph (23):
(i) Payment under the preceding provision of thissection shall not be made –
(23) with respect to amounts expended for med-ical assistance for covered outpatient drugs (asdefined in section 1927(k)(2)) for which the pre-scription was executed in written (and non-elec-tronic) form unless the prescription was executedon a tamper-resistant pad.
(2) EFFECTIVE DATE – The amendments made by para-graph (1) shall apply to prescriptions executed afterSeptember 30, 2007.
(See page 132 at: http://www.rules.house.gov/110/special
_rules/hr2206_senate/hr2206_amnd1_senate.pdf)
Botox seminarsAttendance of seminars does not qualifynurse practitioners to administer Botox, Restalyn or Collagen
The Alabama Board of Medical Examiners has
received information that seminars for certified registered
nurse practitioners (CRNPs) are being conducted with the
implication that attendance qualifies the attendee to per-
form Botox injections. At its May 16, 2007, meeting, the
Board authorized sending a letter to the Alabama Board of
Nursing with a suggestion that the Board of Nursing noti-
fy their licensees that nurses and nurse practitioners can
not administer Botox, Restalyn or Collagen in the state of
Alabama.
Collaborative AgreementsAnnual Fee to accompany collaborative practiceregistration
As of Sept. 1, 2007, a new law will be in effect for
physicians engaged in a collaborative practice agreement.
An annual fee of $100 will be assessed for each collabora-
tive agreement a physician has established. Detailed noti-
fication letters will be mailed in late August to every
physician with a collaborative practice agreement.
A fee notice for each collaborative practice agreement
will be sent with the physician’s annual medical license
and Alabama controlled substance certificate renewals in
early October 2007. The CRNP collaboration fee is due
by Dec. 31, 2007, for the 2008 year. There is no grace
period for late payment. The physician will receive an
approval notice and a certificate of collaborative practice
registration upon receipt of the fee.
Skin biopsies by physician assistantsBoard defines procedures allowed for physicianassistants (PAs)
On May 16, 2007, the Board of Medical Examiners
approved the following:
• PAs are allowed to perform shave excisions/biopsies on
the face, not to exceed 5mm in diameter and not to
extend below the dermis.
• Shave excisions/biopsies on anatomically sensitive
areas, such as eyes and ears, must be evaluated by the
physician prior to treatment.
• Punch biopsies to the face can not exceed 5 mm in
diameter.
Do You Perform Surgery, Treatments or Examinations with any Sedation?If so, you may be required to register with the Alabama Board of Medical
Examiners and maintain specific equipment, procedures and records in youroffice or clinic. Check the Newsletter Links section of the Alabama Board of
Medical Examiners website at www.albme.org to determine whether your practice is required to register.
[Because this Issue of the BME Newsletter has an emphasison prescriptions, the following are questions and answersabout electronically transmitted prescriptions that were com-posed by Joyce C. Altsman, R.Ph., Director of Compliance,Alabama State Board of Pharmacy, and Loren T. Miller, Chief,Policy Unit Liaison and Policy Section of the Office of DiversionControl, Drug Enforcement Administration.]
QUESTION: May a pharmacist fill a prescription for a
Class III, IV or V controlled substance that is “electroni-
cally transmitted” from a physician’s laptop, hand-held
device, notepad, etc., indicating an electronic signature?
ANSWER: No. See Title 21, Sec. 1306.21 and Title 20,
680-X-3-.10.
QUESTION: May a pharmacist fill a prescription for a
Class III, IV or V controlled substance that is “electroni-
cally transmitted” from a physician’s laptop, hand-held
device, notepad, etc., to a pharmacy fax machine indicat-
ing an electronic signature?
ANSWER: No. See Title 21, Sec. 1306.21 and Title 20,
680-X-3-.10.
QUESTION: May a pharmacist fill a prescription for a
Class III, IV or V controlled substance that is “electroni-
cally transmitted” from a physician’s laptop, hand-held
device, notepad, etc. that has been printed and faxed
from the physician’s office to the pharmacy fax machine
indicating an electronic signature?
ANSWER: No. See Title 21, Sec. 1306.21 and Title 20,
680-X-3-.10.
QUESTION: May a pharmacist fill a prescription for a
Class III, IV or V controlled substance that is “electroni-
cally transmitted” from a physician’s laptop, hand-held
device, notepad, etc. that has been printed and faxed
from the physician’s office to the pharmacy fax machine
indicating an electronic signature and also a written sig-
nature of the practitioner?
ANSWER: Yes. See Title 21, Sec. 1306.21 and Title 20,
680-X-3-.10.
QUESTION: With how many certified registered nurse
practitioners (CRNPs) may I collaborate?
ANSWER: Based on changes to the rules in September
2003, there is no longer a specified numerical limit for
CRNPs. Instead the emphasis has been placed on an
FTE (full-time equivalent) limit. This is set at the equiva-
lent of three full-time practitioners. Rule 540-X-6-.04 cur-
rently states: “The physician shall not collaborate with orsupervise any combination of certified registered nursepractitioners, certified nurse midwives and/or assistantsto physicians exceeding one hundred and twenty (120)hours per week (three full-time equivalent positions)unless an exemption is granted under Rule 540-X-8-.12.One full-time equivalent (FTE) is herein described as aperson/persons collectively working forty (40) hours aweek, excluding time on call.”
Theoretically, a physician could collaborate with 120
nurse practitioners working one hour each. However, the
requirement for quality assurance and collaboration time
remains in effect for each of those practitioners and this
could become burdensome. The one exception to the
FTE rule is that no physician may collaborate with more
than four certified nurse midwives at any time (Rule 540-
X-8-.26, Limitations Upon Utilization of Certified Nurse
Midwives) and is still subject to the 120 hour FTE limit.
Any questions regarding any facet of collaborative
practices, please contact the BME Nurse Inspectors,
Cheryl Thomas, MSM, RN, and Patricia Enfinger, RN.
Alabama BME Newsletter and Report
Issue 2 • 20078
BME Q & A
Notice regarding Questions and Answers:The Board of Medical Examiners and the Medical License Commission welcome questions and comments. A
comment or question will be published with the physician’s name who submits the item unless the physicianexpresses a desire that the name be withheld. If a topic is presented that may be of very broad interest, the editormay paraphrase the question or comment, and print it as a clarification. The Board will not respond to anonymousor unsigned comments or questions.
Issue 2 • 2007 9
Alabama BME Newsletter and Report
Editor’s note: This article is, by no means,an authoritative guide but is a reminder forphysicians to plan for unexpected problems.Numerous guides cover the basic and generalconcepts; you should review your specific situ-ation with your own legal and accountingadvisors.
Most physicians anticipate leaving
their practices through retirement in
an orderly process. Unfortunately, a
few will have to close their practices
hastily, due to sudden or unexpected
death, an unpredicted severe disabili-
ty, or other causes. For this reason it
is prudent for every physician to make
contingency plans for closure of their
practices and to have these plans in
writing for the survivors and/or
executor of the estate.
For those in a partnership or group
practice, the procedures are less
extensive. Be certain an agreement is
in place that:
• Outlines the steps to transfer the
departing physician’s assets in the
practice,
• Provides for continued coverage
of patients, and
• Addresses the custody of patients’
medical records.
Keep a written copy of this document,
and any subsequent changes, in a safe
place and instruct family members
and/or the executor about it.
For physicians in solo practice the
tasks may be
especially daunt-
ing, particularly
with the overlay
of the family’s
grief. A written
list of sugges-
tions for the
executor should
be kept in a safe
place. The list
should include:
• Agencies to notify of the physi-
cian’s death:
- Medical Boards in every state
the physician was issued a med-
ical license,
- Drug Enforcement Agency
(DEA),
- Hospital staffs,
- Medical liability insurance carrier,
and
- Medical organizations to which
the physician belongs.
• A sample letter of how to notify
patients, and, if another physician
has been arranged to assume the
patients’ care, such an agreement
should be noted.
• Finally, consider how custody of
the patients’
medical records
will be handled
- Who will take
custody of the
patient’s charts,
- Where charts
will be stored
and
- How will
patients obtain
charts so that
the original or a copy may be
sent to their new physician.
If there are no such arrangements,
leave suggestions of preferences on
how patients should receive continued
medical care.
While such planning may be
uncomfortable, no one knows the
future. Prudent preparation for this
unlikely event will be as helpful to
survivors as the review of a will,
financial plan, and life insurance poli-
cies.
For Your Information…Are you prepared for the unexpected closing of your practice?
OPINIONS OF THE ALABAMA BOARD OF MEDICAL EXAMINERScan be found in the Newsletter Links section of www.albme.org.
Pain Management Guidelines can be found at the
Board of Medical Examiners’website, www.albme.org.
Follow the Newsletter Links section.
It is prudent for every
physician to make
contingency plans for an
unexpected closure
of a practice.
The most importantdifference between agood and indifferentclinician lies in theamount of attentionpaid to the story of apatient.
Course DetailsWho should attend?Doctors of Medicine and Osteopathy, and Advanced Practice Nurses including Certified Registered
Nurse Practitioners and Certified Nurse Midwives involved in a collaborative practice agreement.
What will you learn?1. The application, approval and renewal requirements for CRNP/CNMs and required credentials.
2. The responsibilities of both physicians and nurses in a collaborative practice. Common problems
seen and methods to correct them.
3. The regulations for prescribing drugs, quality assurance review, remote sites and specific
practice settings.
Tuition is only $75 and includes all course materials. In addition, each attendee will receivea resource manual containing the laws governing collaborative agreements, sample forms,checklists, and QA resources!
Alabama BME Newsletter and Report
Issue 2 • 2007 11
Medical Licensure CommissionApril 2007None to date.
Board of Medical ExaminersApril 2007
� On April 11, 2007, the Boardaccepted the voluntary surrender of
the certificate of qualification and
license to practice medicine in
Alabama of Samuel W. Beenken,
MD, license number MD.15438,
Montevallo, AL.
� On April 20, 2007, the Boardentered an Order removing all
restrictions on the certificate of
qualification for a license to prac-
tice medicine in Alabama of Joe
Frank Howell, MD, license num-
ber MD.5737, Prattville, AL.
� On March 31, 2007, Oliver
Wilson Crawford Jr., MD,
license number MD.28100, Ozark,
AL, entered voluntary restrictions
against his certificate of qualifica-
tion for a license to practice medi-
cine in Alabama. This action was
effective April 25, 2007, the date
of initial licensure.
Medical Licensure CommissionMay 2007
� On May 16, 2007, the Commissionentered an Order terminating the
probationary status of the license
to practice medicine in Alabama of
William J. Lupinacci, MD,
license number MD.10601,
Bessemer, AL.
� On May 22, 2007, the Commissionentered a Consent Order placing
on probation the license to practice
medicine or osteopathy in Alabama
of Paul A. Brundage, DO, license
number DO.699, Cleveland, TN.
� On May 24, 2007, the Commissiongranted the application for rein-
statement of license of Janie T.
Bush Teschner, MD, license num-
ber MD.14227, Gadsden, AL, sub-
ject to the condition that she shall
not actively engage in the practice
of medicine except within the con-
fines of a residency or other train-
ing program.
Board of Medical ExaminersMay 2007
� On May 16, 2007, the Boarddenied the application for a certifi-
cate of qualification to practice
medicine in Alabama of John T.Mazzeo, MD, Irving, TX. Dr.
Mazzeo has appealed the Board’s
decision to the Medical Licensure
Commission.
Medical Licensure Commission June 2007
� On June 11, 2007, the Commissionentered an Order removing the
probationary status of the license
to practice medicine in Alabama of
Julian H. Fields, MD, license
number MD.23125, Gilbertown,
AL, subject only to the condition
that he shall not practice obstetrics.
Board of Medical Examiners June 2007
� On June 20, 2007, the Boardaccepted the voluntary surrender of
the certificate of qualification and
license to practice medicine in
Alabama of Samuel Nick Shaw,
MD, license number MD.23886,
Brandon, MS. Dr. Shaw is no
longer authorized to practice medi-
cine in Alabama.
Report of Public Actions of the Medical Licensure Commission and Board of Medical Examiners
Notice regarding CME:Physicians and PAs are required to maintain
documentation of CME attendance and hours earned for a minimum of three years. More information can be
obtained from the Newsletter Links section of the Board’swebsite, www.albme.org.
For some patients, thoughconscious that their condition is perilous, recover their health simplythrough their contentmentwith the goodness of thephysician.